My cancer lost, but my insurer is winning in refusal to pay for treatment [Opinion]

A patient waits in the proton gantry before receiving treatment for a brain tumor at MD Anderson Proton Therapy Center.

Photo: Johnny Hanson, Staff / Houston Chronicle

When Blue Cross Blue Shield planted its flag in Texas, it was committed to providing quality health care. But over time, our state’s largest insurer lost its way.

Last year I was diagnosed with oral cancer. That diagnosis set off a chain of events that left me stuck with a massive bill after BCBS refused to pay for my cancer treatment. So far, they have demanded that I pay back more than $60,000 and when all is said and done my final bill could reach over $100,000. I now find myself in a David versus Goliath battle with the company, fighting over the necessity of the treatment that left me cancer free and without horrible side effects.

My diagnosis was followed by a whirlwind of tests and multiple consultations, after which I was told that I may need to consider traditional radiation therapy. The treatment would destroy my cancer but would also expose healthy tissue in my neck and throat to radiation with life-altering side effects and complications including the possibility of permanently damaged saliva glands, taste buds, jawbone, thyroid and a possible speech impediment.

As a former country radio show host and current voice-over actor for commercials, losing my voice was unthinkable. So, I began looking at other options and learned about proton therapy. It is effective at fighting cancer but without the harmful side effects. Doctors are able to target the bulk of the cancer-fighting proton energy on the cancerous cells while avoiding damage to healthy tissue.

That meant I’d have my voice and would enjoy a quicker recovery. It was a no-brainer. However, the doctors warned me that insurers have a pattern of rubber-stamping denials for proton therapy, even though it is FDA-cleared and approved by Medicare as an effective, covered cancer treatment.

As predicted, BCBS denied my claim, and we fought through three rounds of appeals. The company was using outdated research to claim that proton therapy was “unproven.” They refused to consider the facts of my case, up-to-date research, or the appeals of the cancer care experts at MD Anderson who carefully explained the medical necessity of proton therapy for my specific case.

With my treatment delayed by weeks and my tumor growing, I decided to pay out-of-pocket for proton therapy. As a last resort, I wrote to my state representative who escalated my fight to the Texas Department of Insurance. After the Department’s Enforcement Division got involved, BCBS began to pay claims, and ultimately paid 27 of the 33 treatments.

Ironically, the day after my hometown of Wichita Falls signed a proclamation celebrating BCBS for their dedication to the community, the company sent me 27 letters stating that my proton therapy claims had been paid in error and demanded the funds be returned. So much for delivering “top-notch service.”

Unfortunately, my case is not unique. Insurers have a history of unfair delays and denials targeting cancer patients seeking proton therapy. In fact, insurers initially deny 2 out of every 3 requests according to research by the Alliance for Proton Therapy Access. Cancer patients seeking chemotherapy, prescription drugs and other treatments also experience costly delays and denials. And as in my case, cancer patients cannot wait weeks or months before receiving a final decision about whether their treatment will be covered. We need to be focused on fighting cancer, not our insurers.

Insurers should not be allowed to delay or inappropriately deny a cancer patient’s access to the treatment their expert physicians recommend. As one of the 5 million Texans with BCBS, I’m urging Texas Insurance Commissioner Kent Sullivan to step up and hold insurers accountable. He can do this by adopting and enforcing principles of the Cancer Patients’ Timely Treatment Bill of Rights, a set of common-sense practices that can help ensure cancer patients receive timely and fair access to the care they deserve.

Montgomery is a cancer survivor and advocate with the Alliance for Proton Therapy Access.